Are Foot & Ankle Surgeons Being Adequately Compensated for Ankle Fractures? − An Analysis of Relative Value Units

Abstract

The current relative value units (RVU)-based system is built to reflect the varying presentation of ankle fractures (uni-malleolar vs bi-malleolar vs tri-malleolar) by assigning individual RVUs to different fracture complexities. However, no study has evaluated whether the current RVUs reflect an appropriate compensation per unit time following open reduction internal fixation for uni-malleolar versus bi-malleolar versus tri-malleolar ankle fractures. The 2012 to 2017 American College of Surgeons − National Surgical Quality Improvement Program files were queried using current Procedural Terminology (CPT) codes for patients undergoing open reduction internal fixation for uni-malleolar (CPT-27766,CPT-27769,CPT-27792), bi-malleolar (CPT-27814), and tri-malleolar (CPT-27822, CPT-27823) ankle fractures. A total of 7830 (37.2%) uni-malleolar, 7826 (37.2%) bi-malleolar and 5391 (25.6%) trimalleolar ankle fractures were retrieved. Total RVUs, Mean RVU/minute and Reimbursement rate ($/min) and Mean Reimbursement/case for each fracture type were calculated and compared using Kruskal-Wallis tests. The mean total RVU for each fracture type was as follows: (1) Uni-malleolar: 9.99, (2) Bi-malleolar = 11.71 and 3) Tri-malleolar = 12.87 (p < .001). A statistically significant difference was noted in mean operative time (uni-malleolar = 63.2 vs bi-malleolar = 78.6 vs tri-malleolar = 95.5; p < .001) between the 3 groups. Reimbursement rates ($/min) decreased significantly as fracture complexity increased (uni-malleolar = $7.21/min vs bi-malleolar = $6.75/min vs tri-malleolar = $6.10; p < .001). The average reimbursement/case was $358, $420, and $462 for uni-malleolar, bi-malleolar and tri-malleolar fractures respectively. Foot & ankle surgeons are reimbursed at a higher rate ($/min) for treating a simple uni-malleolar fracture as compared to bi-malleolar and tri-malleolar fractures, despite the higher complexity and longer operative times seen in the latter. The study highlights the need of a change in the RVUs for bi-malleolar and tri-malleolar ankle fractures to ensure that surgeons are adequately reimbursed per unit time for treating a more complex fracture case.

The current fee-for-service health care model in the United States relies on the use of relative value units (RVUs) to identify and calculate physician reimbursements associated with provision of clinical care (1). RVUs are essentially a specific number of ‘units’ that are assigned to the Current Procedural Terminology (CPT) code associated with a clinical care activity (i.e., procedure, office visit, consults etc). Insurance companies multiple these RVUs by a specific conversion factor that is defined by the Center of Medicaid and Medicare Services, to determine reimbursements. The number of RVUs assigned to a certain clinical care provision is reflective of multiple factors, such as physician effort, time and skill, and is usually decided after a yearly review and audit process undertaken by the American Medical Association RVU update committee who base their decisions after considering all concerns voiced by providers, hospital administrators and health policy makers (https://www.ama-assn.org/about/rvs-update-committee-ruc/rbrvs-overview).

Physician work remains the biggest determinant of the number of the RVUS assigned to a system. In the case of surgeries, complex procedures requiring greater effort and longer operative times have higher RVUs to ensure that physicians get an adequately higher reimbursement. However, surgeons have often criticized that the current RVUs are not entirely reflective of the amount of effort that goes into performing a complex surgical case (2–4). For instance, prior research has shown that though revision total joint arthroplasties (TJAs) are complex cases, physicians are reimbursed at a lower rate ($/min) as compared to elective primary TJAs (5–8). Other arthroplasty studies have also voiced concerns on the significantly lower revenue earned by physicians whose practice revolved around taking care of revision TKAs as compared to those who majorly performed revision THAs (9).

Most of the current literature focusing on physician reimbursements for orthopaedic procedures is revolving around TJAs, with no current report evaluating the appropriateness of assigned RVUs in foot & ankle trauma. For the most part, most foot/ankle surgeries usually have a single assigned RVU. However, certain surgeries − such as those for ankle fractures − have different assigned RVUs based on the complexity of the fracture (uni-malleolar vs bi-malleolar vs tri-malleolar). We hypothesized that since tri-malleolar and bi-malleolar ankle fractures are technically more challenging cases, requiring more effort and skill, as compared to uni-malleolar fractures, they should ideally have a higher reimbursement rate (per minute). In order to test our hypothesis, we utilized a national surgical datset to report and statistically analyze differences in (1) mean total RVU, (2) mean RVU/min, (3) reimbursement rate ($)/min and (4) total reimbursement per case between uni-malleolar, bi-malleolar and tri-malleolar ankle fractures.

Patients and Methods

Database and Patient Selection

The 2012–2017 American College of Surgeons − National Surgical Quality Improvement Program files were queried using Current Procedural Terminology codes for patients undergoing open reduction internal fixation for isolated uni-malleolar (CPT-27766,CPT-27769,CPT-27792), bi-malleolar (CPT-27814) and tri-malleolar (CPT-27822, CPT-27823) ankle fractures. Patients receiving surgery for concurrent tibia, hip, femur, pelvic/acetabular and/or upper extremity fractures were excluded from the study to capture a relevant cohort of isolated ankle fractures. Patients receiving concurrent ankle arthroscopy and/or removal of external fixators were removed as these adjunct procedures would have likely increased the operative time and therefore skew our findings. Patients with missing data with regards to operative time, and/or assigned RVUs were excluded from the study.

The variable “WORKRVU” was used to retrieve the RVU associated with the primary CPT codes. RVU/minute of each case was calculated by dividing the total RVU by the operative time. RVU/minute of each case was multiplied by the pre-set Center of Medicaid and Medicare Services conversion factor of $35.8887/RVU to retrieve the reimbursement rate ($/min). Finally, the reimbursement for the whole case was calculated by multiplying the reimbursement rate by the total operative time.

Statistical Analysis

The study cohort was divided into 3 groups, based on the fracture type − (1) Uni-malleolar, (2) Bi-malleolar, and (3) Tri-malleolar ankle fractures. Descriptive and statistical analyses (using Kruskal-Wallis tests) were used to report differences in the mean total RVU, operative time, RVU/min, reimbursement rate and reimbursement/case between the 3 fracture groups. For all statistical purposes, a p value of less than .05 was considered significant. All statistical analysis was performed using SPSSv24 (IBM; Armonk, NY).

Results

Following application of inclusion/exclusion criteria, a total of 21,047 isolated ankle fractures were retrieved − out of which 7830 (37.2%) were uni-malleolar, 7826 (37.2%) were bi-malleolar, and 5391 (25.6%) were tri-malleolar fractures. The mean total RVU for each fracture type was as follows: (1) Uni-malleolar: 9.99, (2) Bi-malleolar = 11.71, and (3) Tri-malleolar = 12.87 (p < .001). A statistically significant difference was noted in mean operative time (un-imalleolar = 63.2 vs bi-malleolar = 78.6 vs tri-malleolar = 95.5; p < .001) between the 3 fracture groups. Reimbursement rates ($/min) decreased significantly as fracture complexity increased (uni-malleolar = $7.21/ min vs bi-malleolar = $6.75/min vs tri-malleolar = $6.10; p < .001). The average reimbursement/case was $358, $420, and $462 for uni-malleolar, bi-malleolar and tri-malleolar fractures respectively (Table).

Table.

Mean RVU, operative time, RVU/min and reimbursement rates for each fracture type

Variable	Uni-Malleolar Ankle Fracture	Bi-Malleolar Ankle Fracture	Tri-Malleolar Ankle Fracture	p Value
Number	7830	7826	5391	-
Mean total RVU	9.99 ± 3.39	11.71 ± 3.02	12.87 ± 3.17	<.001
Mean operative time (mins)	63.21 ± 36.88	78.60 ± 40.13	95.46 ± 50.99	<.001
Mean RVU/min	0.201 ± 0.126	0.188 ± 0.139	0.170 ± 0.142	<.001
Mean reimbursement rate/min	$7.21 ± $4.52/min	$6.75 ± $5.00/min	$6.10 ± $5.08/min	<.001
Average reimbursement/case	$358.4	$420.4	$462.1	<.001

Abbreviation: RVU, relative value units.

Comparisons made using Kruskal-Wallis tests.

A hypothetical case scenario was built to better understand the financial ramifications of our observations. We assumed that a foot & ankle surgeon received 2 tri-malleolar ankle fractures in a single day. Using the mean reimbursement/case and mean operative time, we calculated the total reimbursement from the 2 cases. We then assessed the number of bi-malleolar ankle fractures and uni-malleolar ankle fractures that could be performed completely in the time taken for operating on 2 tri-malleolar ankle fractures, and compared total reimbursements associated with each fracture type. Based on our hypothetical scenario, a foot & ankle surgeon spent 190 minutes fixing 2 tri-malleolar fractures and earning $924 in the process. Within a total operative time of 190 minutes, 3 uni-malleolar ankle fractures and 2 bi-malleolar ankle fractures could be managed completely with an associated earning of $1074 and $840 respectively.

Discussion

Using a national surgical dataset of over 21,000 ankle fractures undergoing open reduction internal fixation, the results identify and highlight significant discrepancies in the current RVU-based physician compensation model. Though tri-malleolar and bi-malleolar fracture types had a statistically higher RVU, this increase was not proportional of the higher operative times that goes into treated a more complex fracture type leading to lower RVUs/minute as compared to uni-malleolar fractures. This implies that despite the higher complexity, effort, skill, and longer operative times required in surgically treating a tri-malleolar ankle fracture, surgeons are reimbursed at a lower rate ($/min) as compared to bi-malleolar and uni-malleolar ankle fractures.

It is important to reiterate that though the average reimbursement of the case increased with rising complexity of fracture type, this increase was largely due to the prolonged operative times required in surgically managing bi-malleolar and tri-malleolar fractures. A more nuanced analysis actually pinpointed that even though surgeons may perform longer and complicated procedures for treating tri-malleolar ankle fractures, they were being reimbursed at a significantly lower rate ($/min) as compared to simple uni-malleolar fractures. This discrepancy of reimbursement rates was further supported by our hypothetical scenario, where we showed that within the time taken to treat 2 tri-malleolar ankle fractures, foot & ankle surgeons can operate on at least 3 uni-malleolar ankle fractures while earning an additional $150 in the process.

Similar discrepancies in the RVU-based system have been noted previously. Recently published reports on TJAs showed that surgeons were being poorly compensated per unit time for performing complex revision cases, as compared to primary ones. With regards to total knee arthroplasties (TKAs), Peterson et al identified that reimbursement rate for primary TKAs was $9.33/min whereas it was $7.90/min for revision TKAs (5). In another study looking at RVU-based compensation of single-component versus double-component revisions, Malik et al (unpublished results) found that even though double-component revisions on average took 45 minutes longer to complete, required more technical effort and skill, the surgeons were reimbursed at a lower rate of $8.00/min as compared to the reimbursement rate of single-component revisions ($9.58/min) a procedure which was vastly less complex and took a shorter amount of time to complete. Among non-arthroplasty literature, Orr et al conducted a similar RVU-based analysis of individuals undergoing posterior instrumentation and found that as the number of spine levels being operated on increased, the reimbursement rate decreased (10). The authors suggested that a possible way to combat such deviations in the reimbursement rates for procedures with increasing complexity (such as spinal instrumentation and/or in our case, ankle fractures) is to treat them in the format of the “incremental tax bracket rate” system (10). With regards to ankle fractures, such an “incremental tax bracket rate” system however might not be applicable due to inherent heterogeneity seen in how different fracture types are fixed.

There are several limitations to the study which need to be taken into context. Firstly, the study assesses and analyzes differences in average RVU-based reimbursement for different ankle fracture type repairs and does not successively delineate between certain patient-level granular factors such as bleeding disorders, obesity and/or other co-morbidities which may increase the physician workload by lengthening the operative time and lowering the RVU/min and reimbursement rates of the procedure. While most insurance companies allow the use of “−22 modifier” to ensure that surgeons taking care of complex cases (such as in obese patients) have higher reimbursements (11), the National Surgical Quality Improvement Program database does not record the presence or absence of this coded modifier. Secondly, we mainly focused our study on assessing reimbursement rates associated with physician workload, since that is essentially the biggest determinant of RVUs, and did not take into account other factors, such as the amount of peri- and post-operative acute care, that also goes into determining the number of RVUs assigned to a CPT code. However, prior research has shown that increasing complexity of ankle fracture type (bi-malleolar vs un-imalleolar) is associated with higher post-operative morbidity and read-missions (12,13) further supporting our concerns on the need of a major re-evaluation of these assigned RVUs.

Foot & ankle surgeons are reimbursed at a higher rate ($/min) for treating a simple uni-malleolar fracture as compared to bi-malleolar and tri-malleolar fractures, despite the higher complexity and longer operative times seen in the latter. The study highlights the need of a change in the RVUs for bi-malleolar and tri-malleolar ankle fractures to ensure that surgeons are adequately reimbursed per unit time for treating a more complex fracture case.